微创腔内治疗急性下肢深静脉血栓和髂静脉严重狭窄及闭塞

Minimally Invasive Endovascular Interventional Treatment for Lower Extremity Deep Venous Thrombosis with Stenosis or Obstruction of Iliac Vein

目的探讨机械性抽吸联合支架植入治疗急性髂、股静脉血栓和闭塞的临床效果及应用价值。方法笔者所在医院自2004年10月至2011年12月期间,收治了273例急性髂、股静脉血栓合并髂静脉狭窄或闭塞患者,左侧235例,右侧38例。局麻下经皮穿刺患侧股静脉入路,对髂、股静脉血栓,在导丝引导下插入8～14F鞘管行机械性抽吸,其中53例插入18～24F特大鞘管行机械性抽吸大块机化性血栓。对股、腘静脉血栓,经健侧股静脉在导丝抓捕技术辅助下,置入翻山鞘管至患侧,在鞘管支撑下导丝轻柔地越过瓣膜插至患侧腘静脉处,沿导丝置入Fogarty球囊导管,在数字减影血管造影(DSA)透视下顺应静脉瓣膜方向将血栓拉至患侧髂静脉内,再经患侧股静脉进行机械性抽吸血栓。在髂静脉血栓机械性清除后,对造影显示的血管狭窄或闭塞段,再进行经皮血管腔内成形术(percutaneous transluminal angioplasty,PTA)和支架植入。结果血栓完全清除(Ⅲ级)219例(80.22%),部分清除(Ⅱ级)49例(17.95%),清除最少(Ⅰ级)5例(1.83%)。支架植入后,治愈235例(86.08%),显效29例(10.62%),好转7例(2.57%),无效2例(0.73%)。总有效率为99.27%(271/273),平均住院时间7.5 d,患肢肿胀和疼痛均于介入治疗后1～2 d内开始消退或减轻。随访疗效:3～6个月血流通畅259例(94.87%);7～12个月血流通畅254例(93.73%),13～24个月血流通畅236例(87.08%),25～36个月血流通畅228例(84.13%)。结论机械性抽吸联合支架植入治疗急性深静脉血栓形成和髂静脉闭塞,疗效显著、病程短,是安全有效的方法。

Objective To discuss the clinical effect and value of stent placement combined with mechanical aspiration thrombectomy for acute iliofemoral venous thrombosis with iliac vein occlusion.Methods From October 2004 to December 2011,interventional treatment were performed in 273 patients with acute iliofemoral venous thrombosis and iliac vein occlusion,including left side of 235 cases and right side of 38 cases.Antegrade femoral vein under local anesthesia,an 8-14F catheter was inserted into iliofemoral vein with the guidance of guide wire to aspirate thrombus directly,53 patients used 18-24F large lumen sheath to aspirate thrombus.As for the femoralpopliteal vein thrombus,a 'cross sheath' was inserted to affected iliac vein with the help of guide wire capture technique,a guide wire was introduced to popliteal vein,then a Fogarty balloon catheter was inserted and extracted thrombus to iliac vein,mechanical aspiration thrombectomy was performed again.After iliofemoral vein thrombus were removed completely,percutaneous transluminal angioplasty(PTA) and stenting were performed for stenosis or occlusion displayed by venography.Results Thrombus removal were completely cleared(degreeⅢ) in 219 cases(80.22%),partly cleared(degreeⅡ) in 49 cases(17.95%),and minimal cleared(degreeⅠ) in 5 cases(1.83%).The effect of stent placement:were cured in 235 cases(86.08%),excellent in 29 cases(10.62%),mild in 2 cases(2.57%),and invalid in 7 cases(0.73%).Total effective rate was 99.27%(271/273),the average days in hospital was 7.5 days.Tumescence and pain of affected limb disappeared or relieved after interventional therapy for 1-2 days.The followe up effect:3-6 months,7-12 months,13-24 months,and 25-36 months after treatment of iliac vein patency were 94.87%,93.73%,87.08%,and 84.13% respectively.Conclusion Mechanical aspiration thrombectomy combined with stent placement for acute lower extremity deep venous thrombosis and iliac vein obstruction is an effective and safe treatment for its notable therapeutic effect and the short hospitalization time.